SECTION II: Please check all appropriate statements. I am objecting this assignment on the grounds that:

Staff not trained or experienced in area assigned Staff not given adequate orientation Inadequate staff for acuity (short staffed) The department was staffed with unqualified personnel The assignment posed a serious threat to health and safety of staff. The assignment posed a potential threat to health and safety of the patients. Staff involuntarily forced to work beyond scheduled hours. Other option

Section III:
Complete to the best of your knowledge the patient/work load and acuity at the time of your objection. From
your assessment, (if applicable) indicate for each acuity level, the number of patients. If there are acuity factors not listed, please specify what they are.
Census and Acuity